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San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Pregram <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To quality for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac:', the toilowing <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> than 20 pounds of medical waste at any one time, maintains a tricking document pursuant to Chapter S, and the <br /> generator or parent organization has on 5le one of the ,allowing: <br /> 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small <br /> quantity generator required to register pursuant to Chapter 4. <br /> 2- Information Document if the generator or parent organization is a smail quantity generator not required to <br /> register pursuant to Chapter 4. <br /> ` PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WIfiH-567 FES TO.__ <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> C1 New G Renewal <br /> Medical Office/Business Name:. <br /> Medical Office]Business Address: State: p Code. <br /> City. Phone <br /> Contact Person: <br /> Storage Facility Name: <br /> Storage Facility Address: State: Zp Cade: <br /> City: <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: State: _ —Zip Code: <br /> City: <br /> ort the medical wase. if not enough space, attach information. <br /> List all employee names and tides authorized to transp <br /> Title: <br /> 1- Name: Title: <br /> 2- Name: Title: <br /> 3- Name: <br /> A copy of this exemption and a tracking document shaii be in employee's possession at all times while transporting medical waste• in <br /> addition, ail copies of medical waste records shall he kept an file at generators or health rare professional's facility' <br /> Applicant Signature: Date: <br /> Title: <br /> Do Not Write Below This line <br /> Date: Expiration Date- <br /> 2.E.H.S. Application Approval: <br /> ,_ / / <br /> EH4502 10-03-96 Date Paid I I <br /> Cash or Check S_ (circle) Acct <br />